One of the rallying cries against fee-for-service medicine is this: since doctors are paid to do things to patients (tests, procedures), they are then incentivized to do more things to patients (tests, procedures) than the patient might actually need.

On Thursday, a wide swath of medical groups joined a campaign to list tests and procedures which are commonly done but risk causing patients more harm than benefit.

This “Choosing Wisely” campaign is from a coalition of doctors’ groups — ranging from the American Academy of Pediatrics to the Society of Thoracic Surgeons — in conjunction with Consumer Reports. Last year, the campaign named 45 tests and procedures patients should look at carefully. This year, 17 doctors’ organizations representing 350,000 physicians released 90 additional tests and procedures.

The goal is to encourage patients and doctors to consider what care is truly necessary, to understand “that when it comes to health care, more is not necessarily better,” Dr. Christine Cassel of the ABIM Foundation said in a statement.

Here are just a few examples of some of their recommendations:

Don’t induce labor or schedule a c-section before 39 weeks pregnancy without a valid medical reason. Delivery before 39 weeks is associated with increased risk of learning disabilities and respiratory problems. (American College of Obstetricians and Gynecologists; American Academy of Family Physicians)

Don’t use feeding tubes in patients with advanced dementia. It does not result in better outcomes. Studies show that helping with eating is a better, evidence-based approach. (American Academy of Hospice and Palliative Medicine; American Geriatrics Society)

Don’t automatically do a CT scan to check a child’s minor head injury. Roughly half of children who visit hospital emergency departments with head injuries are given a CT scan. CT scanning is associated with radiation exposure that may increase future cancer risk. Doctor should observe a child prior to making a decision about needing a CT. (American Academy of Pediatrics)

Fifteen more medical societies are expected to release new or additional lists later this year.

]]>https://ww2.kqed.org/stateofhealth/2013/02/21/just-say-no-doctors-groups-define-more-unnecessary-tests-procedures/feed/0CT scan 13 of Clubs_FlickrMammograms: Strong Evidence That Every Two Years Is Best Option For Older Womenhttps://ww2.kqed.org/stateofhealth/2013/02/05/mammograms-strong-evidence-that-every-two-years-is-best-option-for-older-women/
https://ww2.kqed.org/stateofhealth/2013/02/05/mammograms-strong-evidence-that-every-two-years-is-best-option-for-older-women/#respondTue, 05 Feb 2013 15:00:56 +0000http://blogs.kqed.org/stateofhealth/?p=10370(Photo: U.S. Navy)

A major new study has found that — in older women — mammograms done every two years were as effective as mammograms done annually and led to far fewer false positive results.

The study, published online Tuesday in the Journal of the National Cancer Institute, included more than 140,000 women ages 66 to 89 from across the country.

Frequency of mammograms among women in their 40s and 50s has been the subject of intense debate for more than two decades, but this older group of women has been much less studied.

The women screened annually had a dramatically higher rate of false positives.

A team led by researchers at UC San Francisco sought to answer the question: among older women, if a woman is screened for breast cancer every two years, instead of every year, will a deadly cancer be missed?

“We found that there really was no difference,” Dejana Braithwaite, assistant professor of cancer epidemiology at UCSF and part of the research team, told me. “The women who were screened every two years were not at a greater risk. They did not have a higher probability of being diagnosed with late stage breast cancer compared to those women who were screened every year.”

In addition, the women screened annually had a dramatically higher rate of false positives; they were called back for unnecessary mammograms or biopsies. In the study, nearly half of women screened annually — 48 percent — had a false positive over a 10-year period, versus about 29 percent of women screened every two years.

“The overall message is that the probability of false positive results is much greater with annual screening and yet there is no added benefit,” Braithwaite said.

The U.S. Preventive Services Task Force created a firestorm of controversy in 2009 when it said women ages 50 to 74 should be screened every two years instead of annually. At that time, the task force said that “the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.” Braithwaite says today’s study is one step toward advancing the evidence.

“It doesn’t mean to say that women in (their) 70s and even in their 80s should not be screened. Indeed, if they are in good health — women in their 70s — there is not reason for them not to be screened.” But if they have other health issues, breast cancer screening could end up causing unnecessary harms.

“So there’s a lot of uncertainty about the value of screening in these older age groups, and that’s why we’re trying to address is this gap of information in evidence,” Braithwaite said.

And as the population ages, it’s becoming an “increasingly important question,” she concluded.

Listen to the story:
[audio:http://ww2.kqed.org/stateofhealth/wp-content/uploads/sites/27/2013/02/Mammograms-in-Older-Women.mp3]

To many patients, it may seem unbelievable that their doctors would recommend something that is completely unnecessary. But by some estimates, that’s exactly what happens a third of the time.

Yesterday a broad coalition of medical specialty groups — including cardiologists and family practitioners — as well as Consumer Reports announced a new campaign, Choosing Wisely. It’s a list of 45 tests and procedures that doctors should do much less often for one simple reason: the items on the list are unlikely to be of benefit to the patient.

The idea immediately raised questions of rationing and that’s exactly where KQED’s Forum started off this morning in discussing the new campaign. UCSF’s Dr. Catherine Lucey, who helped to spearhead the Choosing Wisely campaign, swatted that misconception away.

“It’s not rationing,” she explained. “Rationing of health care is when you deny needed care to patients. … Rationing of health care means patients could get better being given a particular drug of subject to a particular test. This is about tests that in many circumstances do not improve quality of life, do not improve quantity of life and potentially could harm patients.”

Among the 45 tests and procedures the campaign says to “question” are: annual EKGs for patients at low risk of heart disease; MRIs for back pain; and antibiotics for mild-to-moderate sinusitis. The operative word here is “question.” Some callers to Forum worried insurance companies would use this information to deny payment, depriving those who might need the test or procedure of something that would be helpful. But Dr. Lucey explained that this is a campaign that was developed by physicians. She said insurance companies had not been involved in the process at all.

“This is not about denying these tests. This is not saying that these tests don’t make a difference for some patients,” Dr. Lucey said. “It’s saying many times they don’t. For instance, nuclear cardiologists said 45 percent of routine screening cardiac procedures, stress tests using nuclear radiology, are done for people who don’t benefit from those tests, so why do them?”

It was about this time that Forum welcomed Dr. John Santa to the program. He’s director of the Health Ratings Center of Consumer Reports which partnered with the doctor’s groups in developing this campaign. (Note: Consumer Reports is generally not a group I associate with supporting rationing).

At the heart of the Choosing Wisely campaign is an acknowledgment that patients and doctors need to share in the decision making about a patient’s treatment. If a patient wants a test or treatment that is unlikely to benefit them, the doctor needs to explain that. Conversely, if your doctor recommends something to you, you should ask questions. As Dr. Santa noted, Consumer Reports has 75 years of history telling consumers about virtually every industry, including what products work well and what products don’t. Now, they find the same desire for information in health care.

“Our surveys of consumers overwhelmingly say they want to have those kinds of conversations,” Santa explained. “They are more and more concerned about cost. They’re concerned about safety.”

But this is where I need to digress from Forum (although I think the entire show is worth a listen; the embedded player is below). I fully support avoiding treatments that are not going to benefit a patient. I also support the concept of shared decision making. The problem is that patients, in general, have so much less knowledge and expertise than doctors.

And this brings me to the story of my good friend Saskia van Dijl, someone who is both smart and forceful. She recently developed a severe kidney infection and was hospitalized at a well-respected Bay Area hospital. When I visited her in the middle of her three day stay — a Saturday — she looked awful. She was receiving IV antibiotics. And she was concerned. While her doctor had not told her directly, the nurses told her they had found an order for a “PICC” line — a peripherally inserted central catheter. It would be inserted in Saskia’s arm, to access a major vein for administration of drugs, like the antibiotics Saskia was receiving.

But PICC lines are prone to infection, and Saskia knew that. She wanted to switch to oral antibiotics when she went home. When the doctor came later, Saskia was clear with her doctor. “I asked point blank,” she told me. “‘Are you absolutely sure there’s not an oral antibiotic that would be as effective?’ … I asked that question three times in three different ways. Lisa, I can’t even tell you, I really did not want the PICC line. I felt like it was way too much.” But the doctor was clear. Saskia got the PICC line — and had to stay in the hospital another night.

The next day, a new doctor was on duty. She took another look and saw a new option, based on Saskia’s bacterial culture. There was an oral antibiotic that could work for her. Saskia asked if the first doctor could have known this, and the answer was ‘yes.’ Within twenty minutes the PICC line was out, and Saskia went home with oral antibiotics. She has recovered fully.

Add the cost of Saskia’s PICC line to that one-third of unnecessary health care in this country.

I caught up with Dr. Lucey after Forum and told her Saskia’s story. She said when a patient pushes back as strongly as Saskia had, it should prompt the doctor to take a second look at the options. “Stop, let’s re-think this,” she said. Of course, Saskia could have demanded a second opinion. But by the time the first doctor got back to her, it was Sunday–not a great day for looking for doctors for second opinions. It’s also hard to rebut a doctor who is telling you “this is your only option” when you’re quite sick and lying in a hospital bed.

I’ve watched the discussion back and forth for years. Patients say doctors never explained all the risks. Doctors say, “Patients walk into my office and demand all these tests.” The Choosing Wisely campaign which explicitly acknowledges doctors’ role in overtreatment is a step forward. Still, if groups of specialists could come up with 45 tests that are generally unnecessary, one might wonder why they didn’t come up with the list a long time ago.

Dr. Lucey told Forum listeners, “Like any other individuals, sometimes we fall into habits. And this campaign is suggesting we need to critically evaluate those habits.”

Hundreds of billions of dollars could be saved if those habits are changed.

Researchers wanted to look at this group because of an “ambiguity of recommendations” for them. While it seems like there’s some ambiguity for the rest of us, the ambiguity here is particularly surprising since age is perhaps the most significant risk factor for many cancers.

The study, “Prevalence of Cancer Screening in Older, Racially Diverse Adults,” appears in the Archives of Internal Medicine and found that, among adults aged 75 to 79, the screening rates for colorectal, breast, cervical and prostate cancer were between 56 and 62 percent. Screening rates are lower for older adults who are not white.

“Some had advocated for high breast and colorectal cancer screening rates in healthy older adults because the incidence and mortality of these cancers increase with age. … Others have advocated for low cancer screening rates in persons older than 75 years because the benefit of continuing screening is uncertain and screening can cause substantial harm, especially in frail, older adults.”

In an interview, Walter spoke of experiences from her own practice. “I have 80-year-olds hiking in mountains … and likely to live a long time, and I have people who have serious medical issues, dementia and life limiting disease.” The types of preventive care she would recommend for these two patients, she says, is very different and not based on age, but on their overall health status.

The study also found that nearly one in ten patients with terminal cancer still received screening tests for breast, cervical or prostate cancer. Walter described cases of older women who have had a hysterectomy, including removal of the cervix, yet still receive Pap smears to test for cervical cancer.

“The thing I try to emphasis is let’s do thoughtful cancer screening. Let’s avoid cancer screening in someone without a cervix, someone who is in a nursing home, very frail.” While people often think of screening tests as fairly benign, a positive result can lead to more and more invasive procedures to confirm a diagnosis, invasive procedures that can be very difficult for frail patients to withstand.

This study underscores the need for doctors to talk with older patients about their overall prognosis. Walter pointed out that screening tests can become a “distraction” from someone’s overall health concerns. “If you had a recent heart attack, that’s your major problem. Any major problem should make you rethink, ‘Why am I looking for an asymptomatic problem that I probably don’t have?'”